Section III: Qualitative information on the fundamental approach to implementation of screening programmes
Part 6 Introduction of novel screening tests taking into account international research results
3 Quantitative description of screening implementation in the EU Member States
3.2 Cervical cancer screening .1 Policy consensus
Cytology-based cervical cancer screening is also widely accepted as a public health policy in the EU.
Programmes according to the definitions used in the present report (see section 2.3) are currently running or being established in 25 of the 27 Member states. Compared to the situation with breast cancer screening, programme implementation varies more markedly and there is substantial deviation from the population-based approach recommended by the Council of the European Union. Population-
18 See previous footnote on Finland.
19 Until 2007 the breast screening guidelines of the Swedish National Board of Health and Welfare accepted regional variation in the targeted age range for breast cancer screening; the current national guidelines recommend the full 40-74-year age range without exception.
based programmes are currently running or being established in 15 Member States (Denmark, Estonia, Finland, France, Hungary, Ireland, Italy, Netherlands, Poland, Portugal, Romania, Slovenia, Spain, Sweden, and the United Kingdom).20 Non-population-based screening programmes as defined in section 2.3 are running in 12 Member States (Austria, Belgium, Bulgaria, Czech Republic, France, Germany, Greece, Latvia, Lithuania, Luxembourg, Slovak Republic, and Spain), in two of which regional population-based programmes are also currently piloted or established (France and Spain, respectively; Fig. 4 a and b, Table 4 a).
3.2.2 Number of persons affected by screening
Significantly larger numbers of women are affected by the cervical cancer screening policies now being implemented in the EU than is the case with breast cancer screening, due to the extended target age range of cervical cancer screening programmes. Nearly 109 million women in the EU are in the age group 30-60 years which corresponds to the minimum age group for cervical cancer screening specified in the currently updated second edition of the European Guidelines for Quality Assurance of Cervical Cancer Screening [15].21 Five out of 10 women in this age group in the EU (51 %, 55 million) are targeted for cervical cancer screening by the 15 Member States which have adopted policies aiming for implementation of population-based screening programmes. Nearly five out of 10 women in this age group in the EU (47%, 51 million) are targeted for cervical cancer screening in the 12 Member States which have adopted policies aiming for implementation of non-population-based screening programmes. If women outside the 30-60-year-old age range are also taken into account, 146 million women are targeted by cervical cancer screening programmes which are currently running or being established in the EU (Fig. 4 a – c, Table 4 a and b).
3.2.3 Programme implementation status
The majority of the 30-60-year-old female population in the EU resides in Member States which have already established cervical cancer screening programmes nationwide. Two out of 10 women aged 30-60 years in the EU (22%) are targeted for cervical cancer screening in seven Member States which have rolled out population-based programmes nationwide (Denmark, Finland, Hungary, Netherlands, Slovenia, Sweden and the United Kingdom). A higher proportion of the women in this age group in the EU (41%) is targeted for cervical cancer screening by the non-population-based programmes established nationwide in 11 other Member states (Austria, Belgium, Bulgaria, Czech Republic, France, Germany, Greece, Latvia, Lithuania, Luxembourg, and the Slovak Republic). Nearly three out of 10 women in this age group in the EU (27%) is targeted by the nationwide population-based cervical screening programmes currently being planned (Ireland and Portugal, 3%), piloted and planned (Romania, 4%), or rolled out (Italy and Poland, 20%) in five Member States. Somewhat less than one in ten women in this age group in the EU (8%) is targeted by regional cervical cancer screening programmes in five Member States, with a non-population-based approach in the established programmes in Spain (7%) and a population-based approach in the established programmes in Ireland and Spain (<1%), in the programme being rolled out in Portugal (<1%), and in the pilot programmes in France(<1%; Fig. 4 a – c, Table 4 a).
20 In Cyprus an Ad hoc committee is planning a nationwide population-based cervical cancer screening programme for women 30-60 years of age based on cytology.
21 The current second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening recom-mends 30-60 years or 30-65 years as the minimum age group to target for cervical cancer screening.
3.2.4 Variation between Member States
The wider variation between the Member States in the way cervical cancer screening is implemented is also evident in programme policies on the duration of the screening interval and the age of women targeted for screening (Table 4 b). A one-year interval between two negative screening tests is the current policy in six member states with cervical screening programmes (Austria, Czech Republic, Germany, Greece, Luxembourg and the Slovak Republic). A two-year screening interval is adopted in one Member State (Bulgaria), and a three-year interval is currently adopted in 14 Member States, nine of which apply this interval to the entire target age group (Belgium, France, Hungary, Italy, Latvia, Lithuania, Poland, Portugal and Slovenia) and five of which also apply a five-year interval to subgroups of participants, depending on age and/or the screening region (Denmark, Ireland, Spain, Sweden and the United Kingdom). A five-year interval is applied to the entire target population in four Member States (Estonia, Finland, Netherlands and Romania).
In all but one of the 25 Member States currently running or establishing cervical cancer screening pro-grammes, the target age group includes at least the age range 30 to 59 years.22 The lowest age targeted by most screening programmes is 30 years in 5 Member States (Estonia, Finland, Lithuania, the Netherlands, and Spain), 25 years in 10 (Belgium, the Czech Republic, France, Hungary, Ireland, Italy, Poland, Portugal, Romania, and the United Kingdom), 23 years in two (Denmark and Sweden), 20 years in four (Germany, Greece, Latvia and Slovenia) and less than 20 years in three Member States (Austria, Luxembourg and the Slovak Republic). The highest age targeted by most programmes for cervical cancer screening is 59 or 60 years in nine (Denmark, Estonia , Finland, Ireland, Lithuania, The Netherlands, Poland, Spain, and Sweden), 64 or 65 years in nine (Belgium, Bulgaria, France, Hungary, Italy, Portugal, Romania, Slovenia and the United Kingdom), and 69 or 70 years in two Member States (the Czech Republic and Latvia). There is no upper age limit on the target population in five Member States (Austria, Germany, Greece, Luxembourg and the Slovak Republic; Table 4 b).
3.2.5 Volume of programme screening
Table 4 b shows the number of women invited to, and attending cervical cancer screening pro-grammes in the EU in a one-year period based on data for 10 and 19 Member states, respectively.
The totals in the table (9.3 million invited and 28.6 million screened) do not include women invited to the population-based screening programmes established nationwide in Denmark and Sweden; the pilot population-based programmes in France and Romania, one of the regional population-based screening programmes in the United Kingdom (Scotland), and the regional population-based pro-grammes in Spain. As for most Member States, the reference year for the data from Poland is 2006, the year before transition to a population-based programme with personal invitation in that Member State. Therefore no invitations are entered in the table for Poland. Data on the number of women attending screening is lacking from the population-based nationwide and pilot programmes in Denmark and France, respectively, as well as from the non-population-based programmes in Austria, Greece, the Slovak Republic and most regions in Spain. If these factors are taken into account, a conservative estimate would yield over 17 million women invited to, and approximately 32 million women attending cervical screening programmes in the EU in 2007.
3.2.6 Volume of non-programme screening
The volume of cervical cancer screening examinations performed outside of publicly mandated screen-ing programmes has been reported for 10 of the 27 EU Member States (over 9 million examinations annually). The available data is insufficient to estimate the actual volume of non-programme examinations in the EU, although the number of examinations is likely to be substantially higher.
22 Note regional variation in the targeted age ranges in some member states: the targeted age ranges indicated in the text for Denmark, France, Finland, Spain and the United Kingdom, in particular, apply to most, but not all regions. The youngest age targeted for cervical cancer screening in Bulgaria is 31 years.